Managing Difficult Patient Encounters

Although most patient encounters with physicians go smoothly, some do not. Most if not all physicians get a difficult patient from time to time. Difficult patients have a common thread: a need for something a provider cannot provide, said Karen Broquet, MD, Associate Professor of Medicine/Psychiatry at the Southern Illinois University School of Medicine in Springfield. “For doctors, it's self-evident that we can't meet patients' needs all the time, but that's not always evident to patients,” she said.

Direct-to-consumer health care advertising has led to a growing number of patients with unrealistic treatment expectations, she noted.

Most of the time, difficult patients are not a major problem. If their behavior interferes with treatment or becomes overwhelming or physically dangerous, there are ways to handle it or work through most conflicts constructively. Doctors also may contribute to a difficult patient encounter. They could just be having a bad day, or it may be a pattern. Doctors who are defensive, fatigued, harried, dogmatic, or arrogant are more likely to run into difficulties with patients, Dr Broquet said. Practices need to identify physicians who, compared with their colleagues, receive more patient complaints or poor ratings related to interpersonal behavior, and then address the problem.

Certain office triggers, such patient or provider lateness to an appointment, may contribute to difficult patient interactions. Practices should create protocols for addressing these problems.

“No doctor of staffer should have to reinvent what to do every time one of these things comes up,” she said. “Setting limits can be a good thing – especially for the patient who really doesn't know that showing up 2 hours late is not okay.”

Internal triggers

Jodi De Luca, PhD, a clinical psychologist at Erie Colorado Counseling, PLLC, and Behavioral Health staff member at Boulder Community Hospital Emergency Department in Boulder, Colorado, emphasizes that stressed out health care providers working long hours and meeting high demands can make difficult patient encounters increasingly challenging. “We are responsible for an individual's overall well-being,” Dr De Luca said. “This alone creates incredible pressure … and our own frustrations, fear of error, and other variables contribute to the challenges of difficult patients.”

Patients' medical issues, loss of control, and fear of procedures also can contribute to difficult encounters. “From an emotional and psychological perspective, a patient's visit with a physician, in particular, can be quite overwhelming,” Dr De Luca said. “Hence, the behavioral manifestations can be very difficult for the health care team to deal with. Physicians and nurses, in particular, bear the brunt of the negative behavior.”

Some types of patients can present greater difficulty than others, such as patients who gets angry when they thinks they are not being treated well. Other challenging patients include those with what Dr Broquet calls “high emotional needs” and self-destructive patients, such as those who do not following treatment recommendations or reject help for addictions and other maladies.

Another difficult patient is the one with many somatic complaints not tied to specific physical conditions. These individuals tend to be high utilizers of health care services who are unhappy because they are not getting better. Often, there is an underlying mental health condition contributing to their behavior, Dr Broquet said.

Managing patients

Working with challenging patients can be a drain on an office's resources. These patients can decrease productivity, waste staff time, reduce time seeing other patients, and increase burnout and resentment toward patients. Calming patients and getting back to treating patients as quickly as possible is imperative. One way to do so is just listening. Dike Drummond, MD, contends that allowing people to be heard typically diffuses bad situations. For this reason, he created the Universal Upset Person Protocol with 6 phrases providers can say to calm someone:

1. “You look really upset.”

2. “Tell me about it.”

3. “I'm so sorry this is happening to you.”

4. “What would you like me to do to help you?

5. “Here's what I'd like us to do.”

6. “Thank you for sharing your feelings; it's important that I understand you today.”

Dr De Luca recommends helping the patient gain a sense of control by using questions like: “What would make things better?” “What options do you propose?” If their recommendations are not workable, offering other realistic options is helpful. Once presenting alternative options to patients, a recommended follow-up question is, “Which do you think is best for you?”

Office staff can also be used to smooth situations by alternating who works with challenging patients so no one person gets the brunt. If possible, bring in staff who has a good relationship with that patient. It may be wise to bring in a third party during visits with known difficult patients, Dr De Luca said.

In rare instances, visits can turn violent. Known high-risk settings include emergency departments, wards holding people with mental health issues, and crowded spaces. The risk of violent encounters, Dr Broquet said, is elevated with the following kinds of patients:

People with a history of violence

Young men

Those who are intoxicated or withdrawing from substances

People with personality disorders or psychotic mental illnesses

Individuals who are delirious, have a head injury, or a history of brain trauma

Patient behaviors that may herald violent outbursts include repetitive movements or phrases, pacing, jumpiness, loud speech, cussing, accusations of conspiring against them, or using discriminatory or sexual language. If a situation rises to the case where someone is yelling or throwing things, providers should focus on safety. The point of maximum benefit from simply listening and being kind has passed, Dr Broquet said.

“Offices might want to have 1 person available on call or a security officer for these situations,” she said. “There is a skill level to working with these patients that everyone can't be trained for.”